CurrentUnitedHealthcarePolicy AL2085

Empire Plan Flexible Formulary Preferred Drug List (partial) — Coverage Criteria

A formulary guide listing commonly prescribed covered drugs, preferred and non-preferred brand options, and utilization management indicators for Empire Plan enrollees and their providers; applies to prescription drug coverage administered by CVS Caremark for the Empire Plan.

Policy Summary

PayerUnitedHealthcare

PolicyEmpire Plan Flexible Formulary Preferred Drug List (partial) — Coverage Criteria

Policy CodePolicy AL2085

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when a drug is annotated with PA and follow the plan's quantity limit (QL) processes where indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipletherapeutic categories listed (partial document)

PA / QL / SGMutilization management legend present

100+individual drug names listed (partial)

Excludedexplicit excluded drug names listed

20+preferred alternative groups listed

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Coverage Criteria

Medications and products listed as excluded under this formulary are the financial responsibility of the enrollee unless a request for a medical exception is approved. Enrollees and prescribers should confirm coverage and copay information via the Empire Plan CVS Caremark portal or member phone line prior to dispensing, as newly FDA‑approved products may be subject to exclusion upon market release.

This excerpt of the formulary contains therapeutic class listings and product groupings (for example, antimalarials and miscellaneous oncology agents) but does not state any additional coverage exclusions or "not medically necessary" statements in these specific segments of the document.

The formulary identifies specific products under the heading "EXCLUDED DRUG NAME(S)." Examples shown include: ACTICLATE, acyclovir cream, ADALIMUMAB‑AATY, ADALIMUMAB‑ADBM, ADALIMUMAB‑FKJP, and topical agents such as adapalene pads and adapalene solution.

Additional products explicitly listed as excluded include (partial list): ARAZLO, ARICEPT 23 MG, ATELVIA, AUVI‑Q, AZOPT, BALCOLTRA, BASAGLAR, BETAPACE, and BRAVELLE. Providers should consult the full excluded‑drug listing for a complete inventory and preferred alternatives.

The excluded‑drug sections continue with additional entries such as fenoprofen tablet, FLECTOR, FLOVENT DISKUS, flucytosine capsule 500 mg, IDACIO, imiquimod cream 3.75%, and multiple insulin preparations (e.g., INSULIN ASPART). These items are designated noncovered unless an applicable exception is authorized.

Within the provided excerpt there are no statements declaring any drug or service as "not medically necessary." The document focuses on formularly listings, utilization flags, and explicit excluded product names in other sections.

Provider Actions and Utilization Management

Prior Authorization

Prior Authorization and Utilization Management Requirements

Certain drugs listed in the formulary are subject to utilization management. Products annotated with PA (Prior Authorization), QL (Quantity Limit), PA/QL, QL/PA, or SGM (Specialty Guideline Management) require the provider to follow the plan's prior authorization, quantity limit, or specialty management processes; failure to obtain required authorization or to meet QL limits may result in claim denial or enrollee financial responsibility.

PA = prior authorization required before coverage may be approved
QL = quantity limits apply; prescriptions exceeding limits may be denied or require PA
PA/QL, QL/PA = combined prior authorization and quantity limit rules may apply
SGM = specialty guideline management; may include specialty quantity limits and provider specialty program procedures

Prior Authorization

Prior authorization note (partial)

The formulary quick-reference and drug lists include partial prior authorization notes and annotations next to specific products (for example, selected incretin mimetics, antiobesity agents, and certain opioid, dermatology, and ED agents are marked with PA, QL, or SGM). Providers must consult the plan portal for the full prior authorization criteria and required documentation.

Background

This formulary is organized by therapeutic class and lists commonly prescribed covered drugs; where generics are available the document indicates preferred agents and identifies brand‑for‑generic or biosimilar designations to guide clinically appropriate, cost‑effective prescribing.

Definitions and Legend

Formulary legend

PAPrior Authorization

PA/QLPrior Authorization then Quantity Limit

QLQuantity Limit

QL/PAQuantity Limit with PA for possible additional quantity

SGM (formulary annotation)

SGM usageSGM appears as an annotation following multiple products (e.g., hepatitis C agents, kinase inhibitors, biologics) indicating a specialty/generic or specialty guideline designation in the formulary.

ExamplesEPCLUSA SGM, HARVONI SGM, dasatinib SGM, REMICADE SGM

Step Therapy and Preferred Alternatives

Guidance	Source
Generics should be considered the first line of prescribing; authorize generic substitution whenever possible.
When no generic is available, preferred brand-name drugs are listed to help identify clinically appropriate, cost‑effective options.

Implication	Source
'B4G' (Brand-for-Generic) designations on SGLT2 inhibitors and combination products imply a formulary-preferred pathway between brand and generic equivalents.
Examples in the formulary include SYNJARDY B4G, XIGDUO XR B4G, FARXIGA B4G and JARDIANCE B4G, indicating B4G mapping for these agents.

Interpretation	Source
Entries annotated with 'PA', 'QL', or similar flags in the quick reference indicate those agents are subject to prior authorization or quantity‑management programs, suggesting utilization management may affect sequencing or access.
The document contains examples such as armodafinil PA (quick reference) and sildenafil QL / tadalafil QL/PA for erectile dysfunction, showing PA/QL annotations in the list.

Preferred alternative example	Source
Preferred alternatives are listed for many non‑preferred drugs, indicating an expected step to the alternative before coverage of the non‑preferred agent (example: ADCIRCA preferred alternative = sildenafil 20 mg SGM).
The Level 3 list and PREFERRED ALTERNATIVE(S) sections explicitly pair non‑preferred drugs with suggested alternatives to guide substitution prior to coverage of the non‑preferred agent.

Therapeutic substitution guidance	Source
Formulary guidance directs prescribers to use therapeutic‑class substitutions and preferred agents (generics, biosimilars) before non‑preferred brands where applicable.
Preferred alternative lists (e.g., diclofenac sodium and other generic NSAIDs listed as alternatives) indicate prescribers should try preferred agents prior to non‑preferred or excluded brands.

Policy expectation	Source
For products listed as EXCLUDED DRUG NAME(S), the formulary provides preferred alternatives; prescribers are expected to select the listed preferred agents (generics or formulary‑preferred drugs) before requesting exceptions or coverage of excluded products.
The document shows excluded drug lists with accompanying PREFERRED ALTERNATIVE(S) (examples include many biologic and small‑molecule exclusions with biosimilar or generic alternatives listed), reinforcing the expectation to use alternatives first.

Quantity Limits (QL)

Quantity limits (general)

Various listed drugsQuantity limits apply where entries are annotated with QL or QL/PA across the quick reference and therapeutic lists.

Examplesfentanyl buccal tablet PA/QL; albendazole QL/PA; lidocaine-prilocaine QL/PA; oxycodone QL/PA

ActionClaims may be limited or denied without adherence to quantity limits; follow plan QL rules at point of fill.

sildenafil — QL

sildenafilAnnotated in the formulary as QL (quantity limit applies).

ContextListed under Erectile Dysfunction quick reference with a QL designation to indicate dispensing limits.

Biosimilars and Specialty Designations

Note

Policy Summary

PayerUnitedHealthcare

PolicyEmpire Plan Flexible Formulary Preferred Drug List (partial) — Coverage Criteria

Policy CodePolicy AL2085

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when a drug is annotated with PA and follow the plan's quantity limit (QL) processes where indicated.

SourceLink

On This Page

Examples of partial PA annotations in the list: liraglutide PA, MOUNJARO PA, OZEMPIC PA, RYBELSUS PA, TRULICITY PA
Antiobesity agents: CONTRAVE PA, SAXENDA PA, WEGOVY PA, ZEPBOUND PA
ED agents: tadalafil QL/PA, sildenafil QL

Note

Prior authorization not specified in excerpt

Some sections of the formulary are drug-class listings or quick-reference entries that do not include explicit prior authorization instructions within the excerpt. These segments still may contain utilization flags elsewhere; check the full plan criteria for authorization and step requirements.

Kinase inhibitors and many therapeutic class lists show SGM annotations but not the detailed PA criteria in this excerpt
Beta-blockers and many common class listings are provided without PA details in the excerpt

Note

Prior authorization not listed in excerpt

Certain parts of the document list products and program tags (e.g., B4G, SGM) without stating explicit prior authorization steps in the excerpt. These program tags can affect coverage and substitution rules; providers should follow plan processes for exceptions and dispensing.

B4G = Brand-for-Generic — may affect formulary preference and copay assignment
SGM = Specialty Guideline Management — may route drugs to specialty review or manufacturer support programs

Prior Authorization

Prior authorization for select agents

Specific agents and classes are explicitly annotated with PA or QL/PA in the formulary and thus require prior authorization per plan rules. Examples include select incretin mimetics (liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) and certain opioid and migraine agents annotated with QL/PA.

Incretin mimetics: liraglutide PA, MOUNJARO PA, OZEMPIC PA, RYBELSUS PA, TRULICITY PA
Opioid products: multiple opioids annotated QL/PA (see opioid analgesics section)
Migraine triptans: eletriptan QL/PA, naratriptan QL/PA, sumatriptan QL/PA, zolmitriptan QL/PA

Prior Authorization

Prior authorization / quantity limits for select ED drugs

Some erectile dysfunction agents carry utilization flags: sildenafil is marked QL and tadalafil is marked QL/PA. Prescriptions may be subject to quantity limits or require prior authorization before additional quantity or coverage is approved.

sildenafil — QL (quantity limits apply)
tadalafil — QL/PA (quantity limit with prior authorization requirement for additional quantities)

Note

Prior authorization not specified in extract

Other excerpts present drug names and preferred/non-preferred lists without explicit prior authorization language; absence of a PA flag in the excerpt does not guarantee no utilization management — verify coverage status on the plan portal.

Drug lists such as contraceptives and diabetic supplies are shown without PA in the excerpt
Always confirm authorization needs via the Empire Plan/CVS Caremark portal

Prior Authorization

Selected dermatology prior authorization/quantity limit

Selected dermatology products are specifically labeled with PA or QL/PA in the formulary. These flags indicate that prior authorization or quantity limits (and corresponding documentation of medical necessity) may be required for coverage.

Acne agents: adapalene (except pads/solution) PA; tretinoin PA; tretinoin gel microsphere PA; AKLIEF and WINLEVI listed
Antifungals: JUBLIA PA; NAFTIN GEL 1% PA
Local anesthetic: lidocaine-prilocaine QL/PA

Documentation Required

Utilization management flags require plan processes

Utilization management flags (PA, QL, SGM, B4G, PA/QL, QL/PA) throughout the list require providers to follow established plan processes for prior authorization, quantity limit exceptions, specialty routing, and documentation. Claims submitted without following these processes risk denial.

Follow the Empire Plan/CVS Caremark prior authorization and appeals processes when a PA is required
Submit supporting clinical documentation for PA requests or medical exception requests as applicable
Specialty agents (SGM) may require enrollment in specialty pharmacy programs or adherence to guideline-based dosing limits

Note

Prior authorization and program tags

The formulary uses program tags that impact coverage and substitution: PA (Prior Authorization), QL (Quantity Limit), B4G (Brand-for-Generic), and SGM (Specialty Guideline Management). These tags may trigger different prior authorization pathways or preferred alternative expectations.

B4G products may be dispensed at generic copayment but subject to specific substitution rules
SGM products are managed through specialty guidelines and may require specific provider or site enrollment

Documentation Required

Prior authorization/QL noted

Prescriptions for agents annotated with PA require submission of prior authorization documentation; agents annotated with QL are subject to quantity limits that may require prior authorization for amounts above the limit. Providers should expect to furnish medical-necessity documentation when requested.

PA = prior authorization documentation required before coverage
QL = quantities beyond the allowed limit require PA or will be denied at point of service
QL/PA or PA/QL may require both processes in sequence

Denial Risk

Enrollee financial responsibility for excluded drugs

Enrollees will be responsible for the full cost of medications and products that are excluded from coverage unless a medical exception is approved. Newly FDA-approved medications may be excluded on initial market release.

Excluded drugs listed under "EXCLUDED DRUG NAME(S)" are generally noncovered
Providers may request a medical exception; enrollee financial responsibility applies until an exception is granted

Billing Rule

Non-preferred brand cost implication

When a generic equivalent exists, a brand-name product may be designated non-preferred. Use of a non-preferred brand when a generic equivalent is available may result in the enrollee paying the non-preferred copayment plus the price difference (Ancillary Charge), up to the full retail cost.

Authorize generic substitution whenever medically appropriate
If prescribing a brand when a generic exists, document reason and counsel patient on potential additional out-of-pocket cost

Note

No explicit authorization or denial criteria provided in this excerpt

This excerpt does not include explicit overall authorization or denial criteria, step-by-step PA forms, or complete documentation checklists. For claim adjudication rules, denial triggers, and full PA criteria, providers must consult the plan portal or the full policy.

No comprehensive PA decision criteria are provided in these excerpts
Check the Empire Plan/CVS Caremark site for operational guidance, PA forms, and clinical criteria

Documentation Required

Documentation notes and requirements

Documentation expectations are not fully specified in these chunks. Where PA, PA/QL, or QL/PA flags exist, supporting documentation of medical necessity (diagnosis, prior therapies, lab results, treatment duration) may be required per plan procedures.

Providers should include relevant clinical notes, prior treatment history, and rationale when submitting PA requests
Specialty agents may require additional documentation per SGM program requirements

Note

SGM marker and specialty management

The listing identifies products with 'SGM' but does not include the SGM program's detailed documentation or enrollment requirements in this excerpt. Providers should contact the plan or specialty pharmacy for SGM operational details.

SGM flagged biologics and specialty therapies often require specialty pharmacy dispensing and adherence to program-specific guidelines
SGM may also affect preferred-alternative expectations in the non-preferred drug lists

Documentation Required

Documentation associated with PA/QL flags

Products labeled with 'PA' or 'QL/PA' (for example, certain dermatology, opioid, and other specialty agents) indicate that documentation supporting medical necessity may be required to obtain authorization. Follow the plan's PA submission instructions for timely review.

Include diagnosis code(s), prior medication trials, and clinical rationale with the PA request
Incomplete documentation can delay authorization and lead to claim denials

Prior Authorization

Follow PA/QL procedures

Providers must follow the plan's PA/QL procedures as outlined by the Empire Plan/CVS Caremark processes. Use the plan portal to submit prior authorization requests, track decisions, and file appeals or medical exceptions.

Log in to www.empireplanrxprogram.com or call the plan support number for PA submission and status
Follow appeal and medical exception procedures if coverage is denied

Step Therapy

Preferred alternatives and substitution guidance

The Level 3 (non-preferred) and excluded drug lists provide preferred alternative suggestions. When a non-preferred or excluded product is prescribed, providers should consider listed preferred alternatives or follow the plan's exception process if the preferred alternative is not clinically appropriate.

Preferred alternatives are suggested but may not be clinically equivalent in all cases—document rationale if requesting exception
Examples: ADCIRCA preferred alternative = sildenafil 20 mg SGM; BYDUREON BCISE PA preferred alternatives include listed incretin mimetics PA

Documentation Required

Documentation & substitution for excluded or non-preferred drugs

When prescribing an excluded product, document the clinical justification and submit a medical exception request as necessary. The formulary's preferred alternatives are intended to guide substitutions and may be required before coverage of a non-preferred or excluded product is approved.

Excluded drugs listed under "EXCLUDED DRUG NAME(S)" are subject to denial without a medical exception
Preferred alternatives may be covered and should be considered before requesting exceptions

Documentation Required

Documentation for non-preferred and specialty agents

Preferred alternatives, SGM, PA, and QL annotations in the non-preferred and specialty lists indicate utilization management expectations for non-preferred and specialty agents. Providers should anticipate PA, QL, or specialty program requirements and include supporting documentation when requesting coverage.

Non-preferred biologics and specialty products often have SGM tags — expect specialty routing and prior authorization
Include prior therapy and clinical rationale when seeking coverage for non-preferred agents

Step Therapy

Step therapy and therapeutic substitution (not detailed)

Step therapy specifics are not detailed in these excerpts. The non-preferred lists and preferred alternatives imply step expectations (try preferred alternatives before non-preferred agents), but explicit step therapy sequences, required trials, or failure criteria are not provided here.

Generics are generally preferred first-line; when a generic exists, brand products may be non-preferred
Formulary entries and preferred-alternative recommendations imply step/therapeutic substitution may be required

ImplicationSGM-marked products are grouped as specialty-managed or savings/biosimilar-designated agents in the quick reference.

SGM marker (note)

Marker placementSGM marker appears adjacent to specific drug names in the list (example: dasatinib SGM; RITUXAN SGM).

Document definitionThe document shows SGM next to kinase inhibitors and biosimilars but does not provide a precise in-text definition in every instance.

Associated sectionsSGM appears across biologic, oncology, hepatitis C, and specialty agent listings in the quick reference.

B4G — Brand-for-generic

B4G definitionB4G = Brand for Generic; brand-name product is dispensed at the generic copayment when designated B4G.

ExamplesSYNJARDY B4G, XIGDUO XR B4G, FARXIGA B4G, JARDIANCE B4G

Formulary implicationB4G designation indicates a formulary preference or special status where brand may be treated at generic copay when applicable.

QL — Quantity Limit

DefinitionQL = Quantity Limit — the drug is subject to a preset dispensing limit at point of fill.

Examples in quick referencesildenafil QL; codeine-acetaminophen QL; fentanyl transdermal QL/PA (quantity limits annotated)

Provider actionDrugs annotated with QL are subject to plan quantity limits and may require adherence to limits to avoid claim denial.

PA — Prior Authorization

DefinitionPA = Prior Authorization — coverage requires prior approval from the plan when this annotation appears.

Examplesliraglutide PA; armodafinil PA; agents annotated with PA in quick reference require prior auth submission.

Antiglaucoma combination agents

Class descriptionTopical combination medications that combine mechanisms (e.g., beta-blocker plus carbonic anhydrase inhibitor or alpha agonist plus beta-blocker) to reduce intraocular pressure.

Examples listedbrimonidine-timolol; dorzolamide-timolol; ROCKLATAN; SIMBRINZA

Therapeutic useUsed to lower intraocular pressure in glaucoma management as combination topical agents.

Beta agonists

Class descriptionBeta agonists are short- and long-acting bronchodilators used for relief of bronchospasm in asthma and COPD.

Examples listedalbuterol, levalbuterol, formoterol, SEREVENT, PROAIR HFA, PROAIR RESPICLICK

Common formulationsInhalation solution, aerosol, and inhaler products listed in quick reference.

PA / QL annotations

PA meaningPA = prior authorization required

QL meaningQL = quantity limit

Quick-reference useAbbreviations in the quick reference (PA, QL) indicate plan-level utilization management that providers must follow; PA denotes authorization requirement and QL denotes dispensing limits.

Level 3 / Non-Preferred Drugs

DefinitionLevel 3 or non-preferred drugs are formulary entries designated as higher-cost or non-preferred; the formulary provides preferred alternatives which may not be clinically equivalent.

Provider implicationPrescribers should consider listed preferred alternatives before using Level 3 agents to align with formulary preferences.

Document noteThe formulary states preferred alternatives are a broad representation and do not necessarily indicate clinical equivalence.

Excluded Drugs

DefinitionExcluded Drugs are products explicitly listed as not covered by the formulary; enrollees are financially responsible unless a medical exception is approved.

ExamplesEXCLUDED DRUG NAME(S) include ACTICLATE, acyclovir cream, ADALIMUMAB-AATY, ARAZLO, ARICEPT 23 MG, AZOPT, fenoprofen tablet, FLECTOR, INSULIN ASPART (excerpt examples)

Provider actionWhen an excluded drug is requested, prescribers should document clinical justification and consider listed preferred alternatives per the formulary.

PA (tag on alternatives)

PA annotationPA annotation appearing beside some alternatives indicates prior authorization is required for those products.

ExamplesOZEMPIC PA; armodafinil PA (entries in quick reference show PA next to selected agents)

ActionSubmit standard PA documentation when prescribing agents marked PA as indicated in the formulary.

SGM / B4G (annotation meaning)

InterpretationSGM and B4G tags indicate biosimilar or designated generic/biosimilar preferred alternatives in the formulary listings.

ExamplesCYLTEZO, ADALIMUMAB-ADAZ SGM, SYNJARDY B4G

ImplicationThese annotations identify preferred biosimilar or brand-for-generic alternatives to reference biologics or branded products.

SGM / PA / QL (combined annotations)

Combined annotationsExamples in the quick reference combine SGM, PA, and QL annotations (e.g., fentanyl buccal tablet PA/QL; certain biologics SGM and PA annotations).

MeaningSGM denotes specialty guideline/biosimilar designation, PA denotes prior authorization, QL denotes quantity limit; combined tags indicate multiple program controls.

Provider actionFollow the plan's prior authorization and quantity-limit processes for products with combined annotations.

Provider implication

Prescribers should expect quantity limits at dispensing for sildenafil as noted in the formulary.

tadalafil — QL/PA

tadalafilAnnotated in the formulary as QL/PA (quantity limit and prior authorization may apply).

ContextListed with tadalafil under Erectile Dysfunction entries indicating both a quantity limit and prior authorization flag.

Provider implicationPrior authorization and quantity-limit processes may apply when prescribing tadalafil; follow plan procedures.

albendazole — QL/PA

albendazoleAnnotated as QL/PA in the formulary listings (anthelmintics group).

ReferenceAlbendazole appears in ANTHELMINTICS with QL/PA designation indicating quantity limit and prior auth may apply.

Provider actionFollow prior authorization and quantity-limit submission processes for albendazole per the formulary.

lidocaine-prilocaine — QL/PA

lidocaine-prilocaineAnnotated as QL/PA under Dermatology, Local Anesthetics.

ContextListed with a QL/PA flag indicating quantity limits and prior authorization may be required at dispensing.

Provider implicationPrescribers should follow PA/QL procedures when requesting lidocaine-prilocaine formulations.

Various — QL annotations

ScopeVarious agents in the quick reference are subject to quantity limits where annotated (see QL or QL/PA flags throughout the list).

Examplesbuprenorphine transdermal QL/PA; oxycodone QL/PA; tramadol QL/PA

ActionConsult the formulary annotations and follow plan QL procedures for affected products to avoid claim issues.

fentanyl buccal tablet — PA/QL

fentanyl buccal tabletAnnotated as PA/QL in the opioid analgesics quick reference (prior authorization and quantity limit apply).

Related entriesFentanyl transmucosal and transdermal formulations have QL/PA or QL/PA-type annotations across opioid listings.

Provider implicationPrior authorization and quantity-limit processes must be followed for fentanyl buccal tablet per formulary guidance.